CIGNA Government Services HomeDME MAC Jurisdiction C HomePart B Home

September 2006 Part B Medicare Bulletin

Posted September 1, 2006

Send this page to a colleague

Table of Contents

INSERT TOPICS - September 2006
PDF Documents
(Includes Base Topics)



Download your free copy of Acrobat Reader

Looking for archived issues of the Medicare Bulletin?

Back to the Top of the PageTop

Full Replacement of and Rescinding Change Request (CR) 3504 - Modification to Online Medicare Secondary Payer Questionnaire

Note: This article was revised on June 15, 2006, because CR4098, on which this article is based, has been superseded by CR5087. To view modifications to the online Medicare Secondary Payer Questionnaire that are effective as of September 11, 2006, please see MLN Matters article MM5087, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5087.pdf on the CMS Web site.

Provider Types Affected
Medicare providers who, upon inpatient or outpatient admissions of Medicare beneficiaries, use a questionnaire to determine other insurance coverage that may be primary to Medicare.

Provider Action Needed

STOP - Impact to You
CR4098 clarifies recent changes made to the "Medicare Secondary Payer Questionnaire."

CAUTION - What You Need to Know
This CR identifies all of the changes that were made to CR3504 and makes additional changes to the model questionnaire. These changes will assist providers in identifying other payers that may be primary to Medicare.

GO - What You Need to Do
Please refer to the Background and Additional Information sections of this article and make certain that, if there are other payers, these situations are identified.

Background
The Centers for Medicare & Medicaid Services (CMS) received information that a prior instruction (CR3504) did not specifically mention all of the changes that were made to the "Medicare Secondary Payer (MSP) Questionnaire." CR4098 identifies all of the changes made as part of CR3504 and makes additional changes to the model questionnaire.

The Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1, available as an attachment to CR4098, provides a model: "Admission Questions to Ask Medicare Beneficiaries." The model contains questions that may be printed out and used as a guide to help identify other payers. (The Web site for accessing CR4098 is provided in the Additional Information section of this article.)

The following bullets identify the changes within the model MSP Questionnaire:

Implementation
The implementation date for the instruction is January 21, 2006.

Additional Information
The official instructions issued to your Medicare carrier or intermediary regarding this change and the model questionnaire can be found at http://www.cms.hhs.gov/transmittals/downloads/R41MSP.pdf on the CMS Web site.

If you have questions, please contact your carrier/intermediary at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

A/B MAC NEWS #1 - First Contract for a Part A/Part B Medicare Administrative Contractor (MAC) To Be Awarded in Near Future

Provider Types Affected
All Medicare physicians, providers, and practitioners that bill Medicare fiscal intermediaries (FIs) or carriers for their services, especially those in the states of Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming

Background
Section 911 of the Medicare Modernization Act (MMA) requires the Secretary to implement Medicare Contracting Reform by 2011. The law mandates that CMS conduct full and open competitions, in compliance with general federal contracting rules, for the work currently handled by fiscal intermediaries and carriers in administering the Medicare fee-for-service program.

Medicare Contracting Reform will:

With Medicare Contracting Reform, providers of health care in the original Medicare program can expect:

Key Points for Providers
CMS soon will announce the result of the first full and open competition for a Part A/Part B Medicare Administrative Contractor (A/B MAC) conducted as part of the agency's Medicare Contracting Reform implementation strategy. This award will be for a single fee-for-service claims processing contract that will combine the workloads for a multi-state jurisdiction currently serviced both by FIs and carriers.

This first A/B MAC award will be for Jurisdiction 3, which includes the states of Arizona, Montana, North Dakota, South Dakota, Utah and Wyoming. Jurisdiction 3 represents three percent of the national fee-for-service Medicare claims volume.

With this contract award, CMS will begin to achieve efficiencies and administrative savings through the consolidation of the traditional cost-reimbursable contracts and by implementing improved contracting processes quickly.

The Request for Proposal (RFP) for the Jurisdiction 3 A/B MAC was released in September 2005. Full implementation of the new contractor is scheduled for July 2007. CMS will work with the current carriers and FIs in Jurisdiction 3, whose contracts will end with the MAC implementation, to ensure a smooth transfer of records and information to the new Jurisdiction 3 A/B MAC.

The carriers and FIs whose contracts will end are Montana Blue Cross Blue Shield, Wyoming Blue Cross, Arizona Blue Cross, and Noridian Administrative Services. CMS recognizes with gratitude the strong commitment by these corporations to serving the Medicare program for more than 40 years. The Jurisdiction 3 A/B MAC contract award will be the first of 15 A/B MAC contracts. Each of these contracts will be for the administration of both the Medicare Part A and Part B benefits in a specified geographic jurisdiction of the country. (See the Additional Information section of this article for the Web page containing a map showing the 15 jurisdictions.) All 15 contracts are to be awarded, and all A/B MACs are to be operational, by October 2011.

CMS has extensive experience in overseeing the successful transfer of Medicare claims processing work from one contractor to another. The agency is committed to ensuring that the implementation of the new A/B MAC environment will be as seamless as possible for the Medicare providers and beneficiaries.

CMS will devote full resources and manage the A/B MAC contract implementation so as to ensure continuity, accuracy, and timeliness in claims processing and issuance of payments. In Jurisdiction 3, CMS plans to implement the new A/B MAC contract by transferring the claims processing workload from the current contractors incrementally (rather than all at once) to ensure that neither providers nor beneficiaries will be adversely affected.

Additional Information
Information on the Jurisdiction 3 A/B MAC procurement, including the scope of work to be performed, is available on the Federal Business Opportunities Web site at http://www1.fbo.gov/spg/HHS/HCFA/AGG/CMS%2D2005%2D0016/Attachments.html

A map displaying the 15 A/B MAC jurisdictions is available on the Medicare Contracting Reform Web site at http://www.cms.hhs.gov/MedicareContractingReform/05_A_BMACJurisdictions.asp#TopOfPage on the CMS Web site. Individual fact sheets and data on each jurisdiction are also available there.

Suppliers may want to consult MLN Matters article SE0628 to see how Medicare Contracting Reform affects durable medical equipment regional carriers (DMERCs). That article is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0628.pdf on the CMS Web site.

Back to the Top of the PageTop

Additional Requirements Necessary to Implement the Revised Health Insurance Claim Form CMS-1500

Provider Types Affected
Physicians and suppliers who bill Medicare carriers including durable medical equipment regional carriers (DMERCs) for their services using the Form CMS-1500.

Key Points

There will be a period of time where both versions of the CMS-1500 will be accepted (08-05 and 12-90 versions). The dual acceptability timeline period for Form CMS-1500 is as follows:

January 2, 2007 - March 30, 2007 Providers can use either the current Form CMS-1500 12-90) version or the revised Form CMS-1500 (08-05) version. Note: Health plans, clearinghouses, and other information support vendors should be able to handle and accept the revised Form CMS-1500 (08-05) by January 2, 2007.
April 2, 2007 The current Form CMS-1500 (12-90) version of the claim form is discontinued; only the revised Form CMS-1500 (08-05) is to be used. Note: All rebilling of claims should use the revised Form CMS-1500 (08-05) from this date forward, even though earlier submissions may have been on the current Form CMS-1500 (12-90).

Background
Form CMS-1500 is one of the basic forms prescribed by CMS for the Medicare program. It is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law 107-105 (ASCA), and the implementing regulation at 42 CFR 424.32. The CMS-1500 form is being revised to accommodate the reporting of the National Provider Identifier (NPI).

Note that a provision in the HIPAA legislation allows for an additional year for small health plans to comply with NPI guidelines. Thus, small plans may need to receive legacy provider numbers on coordination of benefits (COB) transactions through May 23, 2008. CMS will issue requirements for reporting legacy numbers in COB transactions after May 22, 2007.

In a related Change Request, CR4023, CMS required submitters of the Form CMS-1500 (12-90 version) to continue to report Provider Identification Numbers (PINs) and Unique Physician Identification Numbers (UPINs) as applicable.

There were no fields on that version of the form for reporting of NPIs in addition to those legacy identifiers. Change Request 4293 provided guidance for implementing the revised Form CMS-1500 (08-05). This article, based on CR 5060, provides additional Form CMS-1500 (08-05) information for Medicare carriers and DMERCs, related to validation edits and requirements.

Billing Guidelines

Additional Information

When the NPI Number is Effective and Required (May 23, 2007)
To enable proper processing of Form CMS-1500 (08-05) claims and to avoid claim rejections, please be sure to enter the correct identifying information for any numbers entered on the claim. Legacy identifiers are pre-NPI provider identifiers such as:

Additional NPI-Related Information
Additional NPI-related information can be found at http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site. The change log which lists the various changes made to the Form CMS-1500 (08-05) version can be viewed at the NUCC Web site at http://www.nucc.org/images/stories/PDF/change_log.pdf.

MLN Matters article MM4320, "Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange Transactions via Direct Data Entry Screen, or Paper Claim Forms,"
can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.

CR4293, Transmittal Number 899, "Revised Health Insurance Claim Form CMS-1500," provides contractor guidance for implementing the revised Form CMS-1500 (08-05). It can be found at http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf on the CMS Web site.

MLN Matters article MM4023, "Stage 2 Requirements for Use and Editing of National Provider Identifier (NPI) Numbers Received in Electronic Data Interchange (EDI) Transactions, via Direct Data Entry (DDE) Screens, or Paper Claim Forms," can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4023.pdf on the CMS Web site.

CR5060 is the official instruction issued to your carrier or DMERC regarding changes mentioned in this article, MM5060. CR 5060 may be found by going to
http://www.cms.hhs.gov/Transmittals/downloads/R1010CP.pdf on the CMS Web site.

Please refer to your local carrier or DMERC if you have questions about this issue. To find their toll-free phone number, please go to: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

Additional Requirements Necessary to Implement the Revised Health Insurance Claim Form CMS-1500 - CR 5060

Additional Requirements Necessary to Implement the Revised Health Insurance Claim Form CMS-1500 - CR 5060

Back to the Top of the PageTop

Collection of Fee-for-Service Payments Made During Periods of Managed Care Enrollment (Previously CR2801 Program Memorandum Transmittal AB-03-101) - Manualization

Note: This article was revised on July 6, 2006, to reflect revisions made to CR5105, which CMS released on July 3, 2006. The Transmittal number, CR release date, and Web address for accessing CR5105 have been changed. In addition, some references to MA (Medicare Advantage) have been changed to refer to managed care plans. All other information remains the same.

Impact on Providers
This article is based on Change Request (CR) 5105, which was issued to manualize the process that ensures that any duplicate payments for services rendered to Medicare beneficiaries are collected. CR5105 ensures that any fee for-service claims that were approved for payment during a period when the beneficiary was enrolled in a Managed Care Organization are submitted to the normal collection process used by the Medicare contractors (carriers/DMERCs/FIs) for overpayments.

Background
The Centers for Medicare & Medicaid Services (CMS) pays for a beneficiary's medical services more than once when a specific set of circumstances occurs. When CMS data systems recognize a beneficiary has enrolled in a MA Organization, the MA Organization receives capitation payments for the Medicare beneficiary. In some cases, enrollments with retroactive payments are processed. The result is that Medicare may pay for the services rendered during a specific period twice:

Overview of the MA plan Enrollment Process
When an MA plan enrollment is processed retroactively

In essence, the retroactive enrollment triggers a search for fee-for-service claims that were incorrectly paid for services rendered when the beneficiary was covered by the managed care plan. If such claims are found, the system generates an adjustment and initiation by Medicare systems of overpayment recovery procedures. The current policy/procedures, as outlined in CR2801 (Transmittal AB-03-101, dated July 18, 2003) and CR 5105, dictates that:

Note: CR 2801 (Transmittal AB-03-101, dated July 18, 2003) can be found at http://www.cms.hhs.gov/Transmittals/Downloads/AB03101.pdf on the CMS Web site:

Because of the inherent retroactivity in the enrollment process, (e.g., beneficiaries can enroll in plans up to the last day of the month, and the effective date would be the first of the following month), the CWF may receive this information after the enrollment is effective. For this reason, these kinds of adjustments occur routinely.

A variety of the CMS systems issues over the past 18 months have prompted CMS to recently synchronize MA enrollment and disenrollment information for the period September 2003 to April 2006. As a result, providers may have claims that were affected by this synchronization. For details of the impact of this synchronization on providers, please see MLN Matters article, SE0638, which is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0638.pdf on the CMS Web site.

When claims are identified as needing payment recovery, the related remittance advice for the claim adjustment will indicate Reason Code 24, which states: "Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan." Upon receipt, providers are to contact the managed care plan for payment.

Providers who bill carriers will be alerted by their carrier (via letter or alternate method) of the following:

Note: To associate plan identification numbers with the plan name, go to http://www.cms.hhs.gov/HealthPlansGenInfo/claims_processing_20060120.asp#TopOfPage on the CMS Web site.

In summary, CMS issued CR5105 to:

Instructions for accessing CR5105 are in the Additional Information section of this article.

Implementation
The implementation date for the instruction is June 26, 2006.

Additional Information
For complete details, please see the official instruction issued to your carrier, DMERC, intermediary, or RHHI regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R100FM.pdf on the CMS Web site.

Also, if you have any questions, please contact your carrier/DMERC/intermediary/RHHI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

Correction to CR4136: New Waived Tests

CR5131 corrects an incorrect Current Procedural Code (CPT) mentioned in the third sentence of the second paragraph in the background section of the Recurring Update Notification attachment for CR4136. Only this sentence has been revised. All other information remains as it is written in CR4136.

Note: This article was revised on July 11, 2006, to show that the effective date is January 1, 2006 and the implementation date at the top of this page is July 24, 2006. These dates were inadvertently transposed on the original article.

Provider Types Affected
All providers and suppliers billing Medicare carriers for laboratory tests

Background
CR5131 corrects an incorrect Current Procedural Code (CPT) mentioned in the third sentence of the second paragraph in the background section of the Recurring Update Notification attachment for CR4136.

Key Points
This article and CR5131 identifies the correction issued by the Centers for Medicare & Medicaid Services (CMS) regarding the "Waived Tests:"

Implementation
The effective date for this instruction was January 1, 2006, and the correction by CR5131 will be implemented on July 24, 2006.

Additional Information
The official instruction, CR5131, issued to your Medicare carrier regarding this change can be found at
http://www.cms.hhs.gov/transmittals/downloads/R988CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

Debridement of Wounds - LCD Revision

The LCD for Debridement of Wounds has been revised for all states to all CPT codes 97605 and 97606. To view the policy in its entirety, please visit the CMS or CIGNA Government Services Web site.

Back to the Top of the PageTop

Deficit Reduction Act of 2005 - Nine Day Payment Hold

"This message is a reminder for all providers and physicians who bill Medicare contractors for their services.

A brief hold will be placed on Medicare payments for all claims during the last nine days of the Federal fiscal year (September 22 through September 30, 2006).

These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006.

This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.

Please note that payments will not be staggered and no advance payments will be allowed during this nine-day hold.

For more information, please view the MLN Matters Article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5047.pdf."

Back to the Top of the PageTop

Disclosure Desk Reference for Provider Contact Centers

Provider Types Affected
All physicians, providers, and suppliers billing Medicare

Provider Action Needed

STOP - Impact to You
When you call or write a Medicare fee-for-service provider contact center (PCC) to request beneficiary protected health information, the PCC staff, in order to comply with the requirements of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act, will authenticate your identity prior to disclosure.

CAUTION - What You Need to Know
CR5089 revises Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 3, Section 30, and Chapter 6, Section 80, to update the guidance to PCCs for authenticating providers who call or write to request beneficiary protected health information, and to clarify the information they may disclose after authentication.

GO - What You Need to Do
Be prepared to supply the required authentication information when contacting a PCC to request protected health information.

Background
In order to protect the privacy of Medicare beneficiaries and to comply with the requirements of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act, customer service staff at Medicare PCCs must first authenticate the identity of providers/staff that call or write to request beneficiary protected health information before disclosing it to the requestor.

CR5089, from which this article is taken, completely revises Section 30 in Chapter 3 and Section 80 in Chapter 6 of the Medicare Contractor Beneficiary and Provider Communications Manual (Publication 100-9). It updates the PCC Disclosure Desk Reference, the main purpose of which is to protect the privacy of Medicare beneficiaries by ensuring that protected health information is disclosed to providers only when appropriate, to include:

Please note that while new subsections have been added to each chapter/section, this reflects reformatting and revision of existing information rather than new requirements.

Below is the authentication guidance that the PCCs will be using:

Telephone Inquiries

Provider Authentication

CSR Telephone Inquiries - Through May 22, 2007, Customer Service Representatives (CSR) will authenticate providers using provider number and provider name.

Interactive Voice Response (IVR) Telephone Inquiries - Through May 22, 2007, IVRs will authenticate providers using only the provider number.

Note: See "Final Note" below to learn more about provider authentication after May 22, 2007.

Written Inquiries

Provider Authentication
Through May 22, 2007, for written inquiries, PCCs will authenticate providers using provider number and provider name.

Note: See "Final Note" below to learn more about provider authentication after May 22, 2007.

At this point, there are some specific details about provider authentication in written inquiries of which you should be aware.

There is one exception for the requirement to authenticate a written inquiry. An inquiry received on the provider's official letterhead (including e-mails with an attachment on letterhead) will meet provider authentication requirements (no provider identification number required) if the provider's name and address are included in the letterhead and clearly establish the provider's identity.

Further, if multiple addresses are on the letterhead, authentication is considered met as long as one of the addresses matches the address that Medicare has on record for that provider. Thus, make sure that your written inquiries contain all provider practice locations or use the letterhead that has the address that Medicare has on record for you.

Also, please note that requests submitted via fax on provider letterhead will be considered to be written inquiries and are subject to the same authentication requirements as those received in regular mail.However, for such fax (and also for e-mail) submissions, even if all authentication elements are present, the PCC will not fax or e-mail their responses back to you.

Rather, they will send you the requested information by regular mail, or respond to these requests by telephone. In either of these response methods, or if they elect to send you an automated e-mail reply (containing no beneficiary-specific information), they will remind you that such information cannot be disclosed electronically via email or fax and that, in the future, you should send a written inquiry through regular mail or use the IVR for beneficiary-specific information.

And lastly, inquiries received without letterhead, including hardcopy, fax, e-mail, pre-formatted inquiry forms, or inquiries written on Remittance Advice (RAs) or Medicare Summary Notices (MSNs), will be authenticated the same as written inquiries, (explained above) using provider name and the provider number.

Insufficient or Inaccurate Requests
You should also understand that for any protected health information request in which the PCC determines that the authentication elements are insufficient or inaccurate, you will have to provide complete and accurate input before the information will be released to you.

Such requests that are submitted in written form and those on pre-formatted inquiry forms, will be returned in their entirety by regular mail, with a note stating that the requested information will be supplied upon submission of all authentication elements, and identifying which elements are missing or do not match the Medicare record.

Alternatively, if you sent the request by e-mail (containing no protected health information), the PCC may return it by e-mail, or may elect to respond by telephone to obtain the rest of the authentication elements.

Beneficiary Authentication
Regardless of the type of telephone inquiry (CSR or IVR) or written inquiry, PCCs will authenticate four beneficiary data elements before disclosing any beneficiary information:

1) Last name;
2) First name or initial;
3) Health Insurance Claim Number; and
4) Either date of birth (eligibility, next eligible date, Certificate of Medical Necessity (CMN)/Durable Medical Equipment Medicare Administrative Contractor Information Form (DIF) [pre-claim]) or date of service (claim status, CMN/DIF [post- claim]).

Please refer to the disclosure charts attached to CR5089 for specific guidance related to these data elements as well as details on the beneficiary information that will be made available in response to authenticated inquiries. CR5089 is available at http://www.cms.hhs.gov/Transmittals/downloads/R16COM.pdf on the CMS Web site.

Special Instances
Below are three special instances that you should know about.

Overlapping Claims
Overlapping claims (multiple claims with the same or similar dates of service or billing period) occur when a date of service or billing period conflicts with another, indicating that one or the other may be incorrect.

Sometimes this happens when the provider is seeking to avoid have a claim be rejected, for example:

These situations fall into the category of disclosing information needed to bill Medicare properly, and information can be released as long as all authentication elements are met.

Pending Claims
A pending claim is one that is being processed, or has been processed and is pending payment. CSRs can provide information about pending claims, including Internal Control Number (ICN), pay date/amount or denial, as long as all authentication requirements are met.

Providers should note, however, that until payment is actually made or a remittance advice is issued, the information provided could change.

Deceased Beneficiaries
Although the Privacy Act of 1974 does not apply to deceased individuals, the HIPAA Privacy Rule concerning protected health information applies to individuals, both living and deceased. Therefore, PCCs will comply with authentication requirements when responding to requests for information related to deceased beneficiaries.

Final note: More information will be provided in a future MLN Matters article about authentication on and after May 23, 2007, the implementation date for the National Provider Identifier or NPI.

Additional Information
You can find more information about Provider Contact Center guidelines concerning authentication by going to http://www.cms.hhs.gov/Transmittals/downloads/R16COM.pdf on the CMS Web site.

Attached to that CR, you will find the updated Medicare Contractor Beneficiary and Provider Communications Manual (Publication 100.09), Chapter 3 (Provider Inquiries), Section 30 (Disclosure of Information); and Chapter 6 (Provider Customer Service Program), Section 80 (Disclosure of Information).

If you have any questions, please contact your carrier, durable medical equipment (DME) regional carrier, DME Medicare Administrative Contractor (DME MAC), fiscal intermediary, or regional home health intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

GS-CSF Leukine/Sargamostim LCD - Revision

The GS-CSF Leukine/Sargamostim LCD for TN (L6538) NC (L6042) and ID (L9648) has been revised for all Part B states. To view the policy in its entirety, please visit the CIGNA Government Services or CMS Web site.

Back to the Top of the PageTop

FAQ's Announcement

In order to facilitate providers accessing educational information, the Part B Medical Review and Communications departments at CIGNA Government Services recently completed an enhancement to the collection of Part B Medical Review "Frequently Asked Questions" (i.e. "FAQs") available on the Web site. Medical Review has published "Frequently Asked Questions" approximately every quarter since January 2003. These questions address issues related to a variety of procedures, specialties, codes, evaluation and management services, policies, etc. The Web site posts the FAQs in a link to the current or most recent issue as well as links to archived or previous issues. The enhancement recently completed is the creation of a cumulative listing that allows providers to scan through all of the "FAQs" that have been published. In addition to the cumulative listing, there is now a drop down menu that includes several categories of topics to which all related questions have been assigned. Some of the categories of FAQs include:

Ambulatory Surgery Centers
Drugs
Nonphysician practitioners
Screening services
Modifiers
and assorted Physician Specialties

To see this page, follow the link below:
http://www.cignagovernmentservices.com/medicare_dynamic/FAQs/Display.asp

If you have a specific question you don't see addressed in these resources, you may want to submit it via the CIGNA Government Services Online Help Center:
http://www.cignagovernmentservices.com/medicare_dynamic/customer_service/index.html

This is a centralized location to submit inquiries that will be tracked to ensure you receive a response. In order to protect beneficiaries' personal health information, this tool should not be used to inquire about specific claims. For those instances, providers are encouraged to use the customer service toll free telephone lines at 1.866.824.8572.

Back to the Top of the PageTop

Free Print of the Medicare Physician Guide Now Available On the CMS Web site

The Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals is now available in print format free of charge from the Medicare Learning Network at
www.cms.hhs.gov/mlngeninfo on the Centers for Medicare & Medicaid Services Web site. Select "MLN Product Ordering Page" under the Related Links Inside CMS section to place your order.

Back to the Top of the PageTop

Intravenous Immunoglobulin - LCD Revision

The LCD for Intravenous Immunoglobulin has been revised for all Part B states effective July 1, 2006. To view the article in its entirety, please visit the CMS or CIGNA Governement Services Web site.

Back to the Top of the PageTop

July 2006 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File, Effective July 1, 2006, and Revisions to January 2006 and April 2006 Quarterly ASP Medicare Part B Drug Pricing Files

Note: This article was revised on July 17, 2006, to include an additional Web address in the "Additional Information" section. This address houses Part B Drug information and the quarterly ASP Medicare Drug Pricing Files.

Provider Types Affected
Physicians, providers, and suppliers who submit Part A or Part B Fee-for-Service claims to Medicare contractors (fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs), and carriers including durable medical equipment regional carriers (DMERCs)) for services.

Provider Action Needed

STOP - Impact to You
CR5110 provides notice of the updated payment allowance limits for Medicare Part B drugs, effective July 1, 2006 through September 30, 2006, as well as revised payment files for the January 2006, and April 2006 Quarterly ASP Medicare Part B Drug Pricing Files.

CAUTION - What You Need to Know
Certain Medicare Part B drug payment limits have been revised and the Centers for Medicare & Medicaid Services (CMS) updates the payment allowance quarterly. The revised payment limits included in the revised ASP and Not Otherwise Classified (NOC) payment files supersede the payment limits for these codes in any publication published prior to CR5110.

GO - What You Need to Do
Make certain that your billing staffs are aware of this change.

Background
According to Section 303(c) of the Medicare Modernization Act of 2004 (MMA), CMS will update the payment allowances for Medicare Part B drugs on a quarterly basis.

As mentioned in previous articles (see MM4319 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4319.pdf), beginning January 1, 2005, Part B drugs (that are not paid on a cost or prospective payment basis) are paid based on 106 percent of the average sales price (ASP).

Pricing for compounded drugs is performed by the local Medicare contractor.

ESRD Drugs
Additionally, in 2006, all ESRD drugs furnished by both independent and hospital based ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the OPPS, are paid based on the ASP methodology.

The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP.

Beginning January 1, 2006, the payment allowance limits for all ESRD drugs when separately billed by freestanding and hospital-based ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the OPPS, will be paid based on 106 percent of the ASP. CMS will update the payment allowance limits quarterly.

Exceptions
There are exceptions to these general rules and those exceptions are outlined in MLN Matters article MM4319, which can be viewed at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4319.pdf on the CMS Web site.

With regard to the exceptions listed in MM4319, note that the payment allowance limits for infusion drugs furnished through a covered item of durable medical equipment on or after January 1, 2005, will continue to be 95 percent of the AWP reflected in the published compendia as of October 1, 2003, unless the drug is compounded.

The payment allowance limits for infusion drugs furnished through a covered item of durable medical equipment that were not listed in the published compendia as of October 1, 2003, (i.e., new drugs) are 95 percent of the first published AWP, unless the drug is compounded.

Drugs Furnished During Filling or Refilling an Implantable Pump or Reservoir
Physicians (or other authorized practitioners) may be paid for filling or refilling an implantable pump or reservoir when it is medically necessary for the physician (or other practitioner) to do so. Payment for drugs furnished incident to the filling or refilling of an implantable pump or reservoir, is determined under the ASP methodology.

Note that the use of the implantable pump or reservoir must be found medically reasonable and necessary in order to allow payment for the professional service to fill or refill the implantable pump or reservoir and to allow payment for drugs furnished incident to the professional service.

If a physician or other practitioner is prescribing medication for a patient with an implantable pump, a nurse may refill the pump if:

How the ASP Is Calculated
The ASP is calculated using data submitted to CMS by manufacturers on a quarterly basis and each quarter:

The absence or presence of a HCPCS (Healthcare Common Procedure Coding System) code and its associated payment limit does not indicate Medicare coverage of the drug or biological.

Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The carrier processing your claim will make these determinations.

Implementation
The implementation date for the instruction is July 3, 2006.

Additional Information
The Medicare Claims Processing Manual, Publication 100-04, Chapter 17, Drugs and Biologicals, contains information that is pertinent to MM5110. It is located at http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf on the CMS Web site.

Quarterly Part B Drug Pricing files and information are also available at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice on the CMS Web site.

CR5110 is the official instruction issued to your Medicare carrier/FI/RHHI/DMERC regarding changes mentioned in this article. CR5110 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R974CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier/FI/RHHI/DMERC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

Medicare Telehealth Services Update

Provider Types Affected
Providers who bill Medicare carriers and fiscal intermediaries (FIs) for telehealth services

Provider Action Needed

STOP - Impact to You
When billing for telehealth services provided on or after January 1, 2006, do not use current procedure terminology (CPT) codes 99261-99263 (hospital inpatient follow-up consultations) or 99271-99275 (confirmatory consultations). These codes no longer exist, and using them could impact your reimbursement.

CAUTION - What You Need to Know
The American Medical Association has deleted CPT codes 99261-99263 (hospital inpatient follow-up consultations) and codes 99271-99275 (confirmatory consultations). Effective January 1, 2006, these CPT codes no longer exist and were removed from the physician fee schedule.

GO - What You Need to Do
Make sure that your billing staffs are aware that CPT codes 99261-99263 and 99271-99275 are no longer usable for telehealth services.

Background
CR5122, from which this article is taken, is issued to alert you that, effective January 1, 2006, the AMA has deleted the following CPT codes:

Thus, the CPT codes that describe these services (hospital inpatient follow-up consultations - 99261 through 99263 and confirmatory consultations - 99271 through 99275) no longer exist. In response, also effective January 1, 2006, CMS has removed confirmatory consultation and inpatient follow-up consultation from the list of Medicare telehealth services as referenced in the Medicare Benefit Policy Manual (Publication 100-02) and the Medicare Claims Processing Manual (Publication 100-04). The relevant sections of these Manuals (Publication 100-02, Chapter 15, Section 270.2 [List of Medicare Telehealth Services] and Publication 100-04 Chapter 12, Section 190.3 [List of Medicare Telehealth Services]) have been revised to reflect these policy changes.

As displayed in Table 1 below, office and other outpatient consultations and initial inpatient consultations are included in Medicare telehealth consultations as described by CPT codes 99241 through 99255. The table displays the current Medicare telehealth services and CPT and HCPCS codes.

Table 1: Current Medicare Telehealth Services and Associated CPT/HCPCS Codes

Service Service CPT/HCPCS Codes
Consultations 99241 - 99255 as of January 1, 2006
Office or other outpatient visits 99201 - 99215
Individual psychotherapy 90804 - 90809
Pharmacologic management 90862
Psychiatric diagnostic interview examination 90801
End Stage Renal Disease (ESRD) related services G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318
Individual Medical Nutrition Therapy G0270, 97802, and 97803

Additional Information
You can find more information about current Medicare telehealth services and the associated CPT/HCPCS codes in CR 5122, located at http://cms.hhs.gov/Transmittals/downloads/R53BP.pdf for the changes to Publication 100-02, Chapter 15, Section 270.2 (List of Medicare Telehealth Services) and at http://www.cms.hhs.gov/Transmittals/downloads/R997CP.pdf for the changes to Publication 100-04, Chapter 12, Section 190.3 (List of Medicare Telehealth Services).

If you have any questions, please contact your carrier/FI at their toll-free number, which may be found at
http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

Medicare's Common Working File (CWF) Part C (Medicare Advantage Managed Care) Data Exchange and Data Display Changes

Provider Types Affected
Physicians, providers, and suppliers who provide services to Medicare beneficiaries enrolled under Medicare Part C

Impact on Providers
CR5118 provides notice that effective January 2006, Medicare Part C plan contract numbers can begin with a character other than an "H." As a result of changes in the assignment of Medicare Part C plan contract numbers, the entire five-position alpha/numeric Medicare Part C plan contract number will be provided to the common working file (CWF), which is a key file used by Medicare systems to provide beneficiary information to providers.

Currently, the CWF places an "H" in front of the Part C plan number, since prior to January 1, 2006, all plan numbers began with an "H." Once this change is implemented, the correct and complete plan contract numbers will then be on the CWF and will be given to providers when they inquire about Medicare beneficiaries.

Background
CWF contains data indicating when a beneficiary is enrolled under a Medicare Part C contract. Medicare Part C contracts are Medicare Advantage Managed Care Plans that provide Part A and B benefits for beneficiaries enrolled under the contract. CWF receives this Part C data on a data feed from the Enrollment Database (EDB), another Medicare database. Effective January 1, 2006, Part C contract numbers can begin with a letter other than "H" and the Medicare CWF is being modified to handle this change, so correct numbers are sent to providers as part of beneficiary information.

To associate plan identification numbers with the plan name, go to http://www.cms.hhs.gov/HealthPlansGenInfo/claims_processing_20060120.asp#TopOfPage on the CMS Web site.

The number that will appear on CWF will begin with "H." For the following 11 plans, the alpha prefix is actually an "R." Prior to October, when using the Web page look-up tool, make sure to replace the "H" with an "R." The 11 plans are the following:

R3175 R5566 R5863
R5287 R5595 R5941
R5342 R5674 R9943
R5553 R5826

Implementation
The implementation date for the instruction is October 2, 2006.

Additional Information
CR5118 is the official instruction issued to your Medicare carrier/durable medical equipment regional carrier (DMERC) or fiscal intermediary (FI) regarding changes mentioned in this article. CR5118 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R995CP.pdf on the CMS Web site.

If you have questions please contact your Medicare carrier/FI/DMERC at their toll-free number, which
may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Back to the Top of the PageTop

National Provider Identifiers (NPIs) Are Free!

NPI: Get It. Share It. Use It.

As the industry transitions to NPI compliance, remember that there is no charge to get an NPI. Providers can apply online for their NPI, free of charge, by visiting https://nppes.cms.hhs.gov or by calling 1.800.465-3203 to request a paper application. The CMS NPI page, located at http://www.cms.hhs.gov/NationalProvIdentStand/, is the only source for official CMS education and information on the NPI initiative; all products located on this site are free of charge.

CMS continues to urge providers to include legacy identifiers on their NPI applications, not only for Medicare but for all payors. If reporting a Medicaid number, include the associated State name. If providers have already applied for their NPI, CMS asks them to go back into the NPPES and update their information with their legacy identifiers. This information is critical for payors in the development of crosswalks to aid in the transition to the NPI.

REMINDER: The National Plan and Provider Enumeration System (NPPES) will be down for scheduled maintenance on August 2nd and 3rd, and will return to operation on August 4th after 8:00 a.m., Eastern Time.

Getting an NPI is free — not having one can be costly.

Back to the Top of the PageTop

Non-Application of Deductible for Colorectal Cancer Screening Tests

Provider Types Affected
Physicians and providers who provide colorectal cancer screening services to Medicare beneficiaries

Impact on Providers
Effective January 1, 2007, Medicare will waive the annual Medicare Part B deductible for colorectal cancer screening tests billed with the HCPCS codes listed in the following chart. While the deductible will be waived, and will not apply for colorectal cancer screening test services furnished on or after January 1, 2007, the Medicare Part B coinsurance still applies for these screening tests.

HCPCS Screening Code Code Description
G0104 Colorectal cancer screening: Flexible sigmoidoscopy

G0105

G0121

Colorectal cancer screening: Colonoscopy on individual at high risk;

Colorectal cancer screening: Colonoscopy on individual not meeting criteria for high risk
G0106 Colorectal cancer screening: Barium enema as an alternative to G0104, screening sigmoidoscopy
G0120 Colorectal cancer screening: Barium enema as an alternative to G0105, screening colonoscopy

Currently (prior to January 1, 2007, for colorectal cancer screening test services furnished before January 1, 2007), the annual Medicare Part B deductible AND coinsurance apply to the above codes.
Please note that the annual Medicare Part B deductible and coinsurance do not apply for the following tests.

Background
This policy is directed by Section 5113 of the Deficit Reduction Act (DRA) of 2005. It amends Section 1833(b) of the Social Security Act (SSA) by eliminating the requirement of the annual Part B deductible for colorectal cancer screening tests furnished on or after January 1, 2007.

Additional Information
SE0613 "Colorectal Cancer: Preventable, Treatable, and Beatable: Medicare Coverage and Billing for Colorectal Cancer Screening" contains pertinent information. It can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0613.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. This special edition also includes links to other resources related to colorectal cancer screening and Medicare-covered preventive services.

The manual attachment to CR5127 (Medicare Claims Processing Manual, Chapter 18, "Preventive and Screening Services", Section 60.1 "Colorectal Cancer Screening; Payment") contains additional information about colorectal cancer screening. CR 5127 is the official instruction issued to your Medicare carrier or fiscal intermediary (FI) regarding changes mentioned in this article. CR 5127 may be found at http://www.cms.hhs.gov/Transmittals/downloads/R1004CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier or FI at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site

Back to the Top of the PageTop

Non-Physician Practitioner (NPP) Payment for Care Plan Oversight (CPO)

Note: This article was revised on July 17, 2006, to reflect a correction made to related CR4374. CR4374 was corrected to show, in one statement, that HCPCS code G0182 refers to hospice oversight services, not home health services. This article was revised to replace "home health" to "hospice" in the 4th bullet point on page 3. The CR release date, transmittal number, and Web address were also changed; but all other information remains the same.

Provider Types Affected
Non-Physician Practitioners (NPPs) and suppliers billing Medicare carriers for home health CPO services

Provider Action Needed

STOP - Impact to You
This article is based on Change Request (CR) 4374 which clarifies the policy associated with NPPs billing for physician home health care plan oversight (CPO).

CAUTION - What You Need to Know
The manual revision in CR4374 effectuates a revision to the policy that the same provider that signs the plan of care does not have to be the same provider that bills for physician care plan oversight. Effective January 1, 2005, NPPs must meet certain conditions to be eligible for payment for home health care plan oversight services even though they may not sign the plan of care. This CR clarifies those conditions.

CR4374 clarifies the policy associated with NPPs billing for physician hospice CPO and clarifies the HCPCS codes for CPO. It temporarily waives the requirement to include the Home Health Agency (HHA) or hospice provider number on a CPO claim since there is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice number. CR4374 also states that the physician who bills CPO must be the same physician who signs the plan of care.

GO - What You Need to Do
See the Background section of this article for further details regarding these changes.

Background
Physician Care Plan Oversight (CPO) is paid under the Medicare Physician Fee Schedule (MPFS), and due to a provision in the Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 180), Non-Physician Practitioners (NPPs) have been prohibited from billing for this service in a home health setting.

The current manual section (Section 180) provides that the physician who signs the plan of care for home health services must be the same person that bills for physician CPO. Since only a physician can sign the plan of care for home health services, NPPs have been unable to bill for physician home health CPO.

Under the Final Physician Fee Schedule Rule, published in the Federal Register on November 15, 2004, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), practicing within the scope of state law, may bill for CPO.

The intention of the Centers for Medicare & Medicaid Services (CMS), as outlined in later portions of the Medicare Claims Processing Manual, was to allow NPPs to bill for physician CPO within their state scope of practice. The current inconsistency in Section 180 will not allow NPPs to be paid for this service.

CR4374 revises the policy that states that the same provider that signs the plan of care does not have to be the same provider that bills for physician CPO. In addition, the Medicare Claims Processing Manual (Publication 100-04, Chapter 11, Section 40.1.3.1) has been revised to clarify CPO billing requirements for beneficiaries who have elected the hospice benefit.

Currently there is no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice number required for a CPO claim. For this reason, the requirement to include the HHA or hospice provider number on a CPO claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for CPO claims.

For services furnished on or after January 1, 2005, your carrier will allow NPPs to bill for physician home health CPO even though they cannot 1) certify a patient for home health services and 2) sign the plan of care.

For beneficiaries who have elected the hospice benefit, physicians or NPPs who have been identified by a beneficiary to be his or her attending physician may submit claims for CPO.

Note: For physicians or NPs who are employed by a hospice agency, CPO is not separately payable.

CR4374 instructs your carrier to:

Implementation
The implementation date for CR4374 is October 2, 2006.

Additional Information
For complete details, please see the official instruction issued to your carrier regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R999CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier at their toll-free number, which may be found at
http://www.cms.hhs.gov/apps/contacts/ on the CMS Web site.

Back to the Top of the PageTop

NPI ALERT: NPPES Downtime

NPI ALERT! The National Plan and Provider Enumeration System (NPPES) will be down for scheduled maintenance on August 2nd and 3rd , and will return to operation on August 4th after 8:00 a.m., Eastern Time.

Back to the Top of the PageTop

NPI Information Alert

Oct 2, 2006 - May 22, 2007:
CMS systems will accept an existing legacy Medicare billing number and/or an NPI on claims. If there is any issue with the provider's NPI and no Medicare legacy identifier is submitted, the provider may not be paid for the claim.

Therefore, Medicare strongly recommends that providers, clearinghouses, and billing services continue to submit the Medicare legacy identifier as a secondary identifier.

This information can be found at: www.cms.hhs.gov/NationalProvIdentStand/06_implementation.asp#TopOfPage

Back to the Top of the PageTop

Reminder to Enumerate; Countdown Has Begun

Countdown has begun; do you have your NPI? Don't risk disruption to your cash flow - Get your NPI now! National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every healthcare provider needs to get an NPI! Learn more about NPI and how to apply by visiting www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

This page also contains a section for Medicare Fee-For-Service (FFS) providers with helpful information on the Medicare NPI implementation. A Countdown Clock is now available on this page to remind health care providers of the number of days left before the compliance date; bookmark this page as new information and resources will continue to be posted.

For more information on private industry NPI outreach, visit the Workgroup for Electronic Data Interchange (WEDI) NPI Outreach Initiative Web site at http://www.wedi.org/npioi/index.shtml on the Web.

Back to the Top of the PageTop

Revised 2006 Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Files - Correction

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including durable medical equipment (DME) regional carriers (DMERCs) and DME Medicare Administrative Contractors (DME MACs), and/or fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), for services paid under the DMEPOS Fee Schedule.

Background
The purpose of this Special Edition article is to alert providers to the revision to the fee schedule regarding DME Fee Schedule Amounts for Transcutaneous Electrical Joint Stimulation Device System Healthcare Common Procedure Coding System (HCPCS) Code E0762.

Key Points

Additional Information
If you have questions, please contact your Medicare carrier, DMERC, DME MAC, FI, or RHHI at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
Transmittal 928 can be found at http://www.cms.hhs.gov/Transmittals/downloads/R928CP.pdf on the CMS Web site.

Back to the Top of the PageTop

rG-Filgrastim/Neupogen LCD - Revision

The rG-Filgrastim/Neupogen LCD for TN (L6256) NC (L6533) and ID (L9642) has been revised for all Part B states. To view the policy in its entirety, please visit the CIGNA Government Services or CMS Web site

Back to the Top of the PageTop

Stage 2 National Provider Identifier (NPI) Changes for Transaction 835, and Standard Paper Remittance Advice, and Changes in Medicare Claims Processing Manual, Chapter 22 ─ Remittance Advice

Provider Types Affected
All Medicare physicians, providers, suppliers, and billing staff who submit claims for services to Medicare contractors (fiscal intermediaries (FIs), regional home health intermediaries (RHHIs), carriers, and durable medical equipment regional carriers (DMERCs) and durable medical equipment administrative contractors (DME MACs))

Background
This article instructs the Shared System Maintainers and FIs, RHHIs, carriers, and DMERCs/DME MACs how to report Medicare legacy numbers and NPIs on a Health Insurance Portability and Accountability Act (HIPAA) compliant Electronic Remittance Advice (ERA) - transaction 835, and Standard Paper Remittance (SPR) advice, any output using PC Print or Medicare Remit Easy Print (MREP) between October 2, 2006, and May 22, 2007.

The Centers for Medicare & Medicaid Services (CMS) has defined legacy provider identifiers to include OSCAR, National Supplier Clearinghouse (NSC), Provider Identification Numbers (PIN), National Council of Prescription Drug Plans (NCPDP) pharmacy identifiers, and Unique Physician Identification Numbers (UPINs). CMS's definition of legacy numbers does not include taxpayer identifier numbers (TIN) such as Employer Identification Numbers (EINs) or Social Security Numbers (SSNs).

Medicare has published CR4320 (http://www.cms.hhs.gov/Transmittals/downloads/R204OTN.pdf) instructing
its contractors how to properly use and edit NPIs received in electronic data interchange transactions, via Direct Data Entry screens, or on paper claim forms. Providers need to be aware that these instructions that impact contractors will also impact the content of their SPR, ERA, and their PC print and MREP software.

The following dates outline the regulations from January 2006 forward and are as follows:

Medicare providers may want to be aware of the following Stage 2 scenarios so that they are compliant with claims regulations and receive payments in a timely manner.

Key Points

During Stage 2, if an NPI is received on the claim, it will be cross walked to the Medicare legacy number(s) for processing.

The crosswalk may result in:
Scenario I: Single NPI cross walked to Single legacy number
Scenario II: Multiple NPIs cross walked to Single Medicare legacy number
Scenario III: Single NPI cross walked to Multiple Medicare legacy numbers

Note: The Standard Paper Remittance for institutional providers would include NPI information at the claim level. NPI information for professional providers and suppliers would be sent at the service level.

CMS will adjudicate claims based upon Medicare legacy number(s) even when NPIs are received and validated. The Remittance Advice (RA) may be generated for claims with the same legacy numbers but and different NPIs. These claims with different NPIs will be rolled up and reported in a single RA accompanied by one check or electronic funds transfer (EFT).

During Stage 2, Medicare will report both the legacy number(s) and NPI(s) to providers enabling them to track payments and adjustments by both identifiers. The Companion Documents will be updated to reflect these changes and the updated documents will be posted at http://www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp#TopOfPage on the CMS Web site.

Scenario I - Single NPI cross walked to single legacy number:

  1. ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the legacy number in the REF segment as Payee Additional ID. Then add the NPI at the claim and/or at the service level, if needed.
  2. SPR: Insert the legacy number at the header level and the NPI at the claim and/or at the service level. if needed.
  3. PC Print Software: Show the legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
  4. MREP software: Show the legacy number at the header level and the NPI at the claim and/or at the service level, if needed.

Scenario II: Multiple NPIs cross walked to Single Medicare legacy number:

  1. ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the legacy number in the REF segment as Payee Additional ID. Then add the specific NPIs at the claim and/or at the service level, if needed. The specific NPI associate with the claim(s)/service lines included in the ERA will need to be identified using additional information provided on the claim.
  2. SPR: Insert the legacy number at the header level. Add the specific NPIs at the claim and/or at the service level, if needed.
  3. PC Print Software: Show the legacy number at the header level and the specific NPI at the claim and/or at the service level, if needed.
  4. MREP software: Show the legacy number at the header level and the specific NPI at the claim and/or at the service level, if needed.

Scenario III: Single NPI cross walked to Multiple Medicare legacy numbers:

  1. ERA: Under this scenario, use the TIN (EIN/SSN) at the Payee level as the Payee ID, and the appropriate legacy number in the REF segment as Payee Additional ID. Then add the NPI at the claim and/or at the service level, if needed. (Under this scenario, if there are 50 claims with the same NPI and that NPI crosswalks to five legacy numbers, we will issue 5 separate RAs and five separate checks/EFTs per each legacy number.
  2. SPR: Insert the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
  3. PC Print Software: Show the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.
  4. MREP software: Show the appropriate legacy number at the header level and the NPI at the claim and/or at the service level, if needed.

Implementation
The implementation date for this instruction is October 2, 2006.

Additional Information
The official instructions issued to your Medicare FI, Carrier, RHHI, DMERC, or DME MAC regarding this change can be found at http://www.cms.hhs.gov/transmittals/downloads/R996CP.pdf on the CMS Web site. The revised sections of Chapter 22—Remittance Advice of the Medicare Claims Processing Manual is attached to CR5081

If you have questions, please contact your Medicare carrier, FI, RHHI, DMERC, or DME MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
The MLN Matters article that provides additional information about Stage 1 Use of NPI is at the following address is available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4320.pdf on the CMS Web site.

Back to the Top of the PageTop

Teleconferences On Various Topics Including NPI, E-Prescribing Pilot, And Electronic Health Records

Please feel free to join in a free audio conference sponsored by Atlanta and Dallas CMS Regions regarding the "NPI Panel Discussion."

For more information about this call and future teleconference dates and topics, please see below:

Southern Healthcare Administrative Regional Process Presents Free Teleconferences!

When: 1:00 - 2:00 PM, ET, Wednesday, July 19, 2006
"NPI Panel Discussion" NCHICA (North Carolina Healthcare Information Communications Alliance) will join the SHARPWorkGroup and CMS in presenting a panel discussion of NPI implementation issues. A panel of industry experts representing Blue Cross and Blue Shield of NC, MedCost, The SSI Group, North Carolina Division of Medical Assistance (Medicaid), Availity, Wake Forest University Baptist Medical Center, and CMS will discuss and take your questions.

1:00 - 2:00 PM ET, Wednesday, August 2, 2006
"E-Prescribing Pilot"
This presentation will provide an overview and status of the CMS sponsored E-Prescribing pilot.

Presenters: Denise Buenning and Andrew Morgan, CMS

1:00 - 2:00 PM ET, Wednesday, August 16, 2006
"Electronic Health Records - Physician Perspective"
Dr. Jim Morrow with the North Fulton Family Medicine will discuss choosing an EHR system. He will share his experiences and lessons learned.

1:00 - 2:00 pm ET, Wednesday , August 23, 2006
"Electronic Health Records - RHIO Perspective"
Liesa Jenkins, Executive Director of CareSpark, will provide an overview of CareSpark and of its experience in improving the health of people in Northeast TN and Southwest VA through collaborative use of health information.

SPECIAL NOTE: Please call 877.203.0044 15 minutes prior to call start time and provide the conference ID number.
July 19, 2006 ID # 2512398
August 2, 2006 ID # 2512410
August 16, 2006 ID # 2512447
August 23, 2006 ID # 2512465
Call sponsored by CMS Regions IV and VI

Back to the Top of the PageTop

Therapy Caps Exception Process

Note: This article was revised on July 3, 2006, to modify the transmittal number and Web address for the change made to the Medicare Benefit Policy Manual. All other information remains the same.

Provider Types Affected
Providers, physicians, and non-physician practitioners (NPPs) who bill Medicare contractors (fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs), and carriers) under the Part B benefit for therapy services

Key Points

Outpatient rehabilitation services include:

Combined annual limit for 2006 is $1,740; and

You may submit a request, with supporting documentation, for a specific number (not to exceed 15 future treatment days for each discipline of occupational therapy, physical therapy, and speech language pathology services) of additional therapy visits.

Background
Financial limitations on Medicare-covered therapy services (therapy caps) were initiated by the Balanced Budget Act of 1997. These caps were implemented in 1999 and for a short time in 2003. Congress placed moratoria on the limits for 2004 and 2005.

The moratoria are no longer in place, and caps were implemented on January 1, 2006. Congress has provided that exceptions to these dollar limitations of $1,740 for each cap in 2006 may be made when provision of additional therapy services is determined to be medically necessary.

Additional Information

Billing Guidelines

This allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.

Documentation
Providers who believe that it is medically necessary for their patient to receive therapy services in excess of the therapy cap limitations (and the patient does not fall into the automatically excepted categories mentioned above) must submit documentation, sufficient to support medical necessity, in accordance with the revised Medicare Benefit Policy Manual, Pub.100-02, Chapter 15, Section 220.3; and the revised Medicare Claims Processing Manual, Pub. 100-04, Chapter 5, Sections 10.2 and 20, with the request for treatment days in excess of those payable under the therapy cap.

These manual sections contain important definitions, as well as examples of acceptable documentation, and are attached to CR4364. CR4364 is in three parts, one each for the revised manuals, i.e.:

The following types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise:

  1. Evaluation and Certified Plan of Care - 1-2 documents.
  2. Certification - Physician/NPP approval of the plan required 30 days after initial treatment-or delayed certification.
  3. Clinician-signed Interval Progress Reports (when treatment exceeds 10 treatment days or 30 days) - These must be sufficient to explain the beneficiary's current functional status and need for continued therapy with the request for therapy visits in excess of those payable under the therapy cap. This is not required to be provided daily in treatment encounter notes or for an incomplete interval when unexpected discontinuation of treatment occurs.
  4. Treatment Encounter Notes - The Treatment Encounter Note is acceptable if it records the name of the treatment; intervention, or activity provided; the time spent in services represented by timed codes; the total treatment time; and the identity of the individual providing the intervention. These may substitute for Progress Reports if they contain the requirements of interval progress reports at least once every 10 treatment days or once in the interval.
  5. For therapy caps exceptions purposes, records justifying services over the cap, either included in the above or as a separate document.

Please see the revised Section 220.3 of the Medicare Claims Processing Manual located at http://www.cms.hhs.gov/Transmittals/downloads/R855CP.pdf for more details about the types of documentation required and explanations of what that documentation should contain.

When reviewing documentation, Medicare contractors will:

Medicare Contractor Decisions
If determined to be medically necessary, your Medicare contractor will grant additional treatment days for occupational therapy, physical therapy, and speech language pathology.

It is preferable that the request for exception be received before the therapy cap is actually exceeded. However, your Medicare contractor will approve additional therapy treatment days retroactively if they are deemed medically necessary, in the exceptional circumstance where a timely request for exception from the therapy cap is not received before the therapy cap is surpassed.

Your Medicare contractor may also approve additional therapy visits already provided when the request is accompanied by documentation supporting medical necessity of the services.

Please note that outpatient therapy services appropriately provided by assistants or qualified personnel will be considered covered services only when the supervising clinician personally performs or participates actively in at least one treatment session during an interval of treatment. Claims for services above the cap that are not deemed medically necessary will be denied as a benefit category denial.

If your Medicare contractor does not make a decision within 10 business days of receipt of the request and documentation, then the decision for therapy cap exception is considered to be deemed approved as medically necessary for the number of future visits requested (not to exceed 15).

Notification
You will be notified as to whether or not an exception to the cap has been made (and if so, for how many additional future visits) as soon as practicable once the contractor has made its decision.

This notification is not an initial determination and, therefore, does not carry with it administrative appeal rights. For examples of the standard letters from the Medicare Program Integrity Manual, 100-8, Section 3.3.1.2, please refer to the Attachments to CR4364. The examples include:

Revised Medicare Summary Notice (MSN) Messages
The MSN messages (17.13; 38.18) are revised to inform beneficiaries about the therapy caps and approved medically necessary exceptions. These notices are also part of CR4364.

Once again, there are three transmittals that comprise CR4364. They are:

If you have any questions, contact your Medicare contractor at their toll-free number, which is available at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site


An ISO 9001:2000 certified company

Home | About Us | Careers | Site Map | Disclaimer | Web Site Feedback | Contact Us


Centers for Medicare & Medicaid Services